Summary & Overview
CPT 99394: Preventive Medicine Evaluation for Established Adolescent Patients
CPT code 99394 represents a comprehensive preventive medicine reevaluation and management service for established adolescent patients aged 12 to 17 years. This code is widely used across the United States to support routine health maintenance, including history-taking, physical examination, counseling, and risk factor reduction interventions. The service is typically provided in an office setting and is a cornerstone of preventive care for adolescents, addressing both physical and behavioral health needs.
Major national payers such as Aetna, Blue Cross Blue Shield, Cigna Health, and UnitedHealthcare recognize and reimburse for this code, underscoring its importance in standard preventive medicine practices. The publication provides an overview of payer coverage, clinical context, and relevant policy updates for 99394. Readers will gain insights into benchmarks for utilization, common billing practices, and the role of this code in adolescent health management. The analysis also highlights associated modifiers, provider taxonomies, and ICD-10 diagnoses relevant to preventive medicine visits, offering a comprehensive resource for understanding the scope and application of 99394 in clinical and billing workflows.
CPT Code Overview
CPT code 99394 is used for periodic comprehensive preventive medicine reevaluation and management of an established adolescent patient, specifically those aged 12 through 17 years. This service includes an age and gender appropriate history, examination, counseling, anticipatory guidance, risk factor reduction interventions, and the ordering of laboratory or diagnostic procedures as needed. The typical site of service for this evaluation and management is the office setting (Place of Service 11). This code is part of the preventive medicine evaluation and management (E/M) service line, focusing on routine health maintenance and preventive care for adolescent patients.
Clinical & Coding Specifications
Clinical Context
A 15-year-old established patient presents to the office for their annual preventive medicine visit. The provider conducts a comprehensive, age-appropriate history and physical examination, including assessment of growth, development, and risk factors. Counseling is provided on topics such as nutrition, exercise, substance use, and anticipatory guidance relevant to adolescence. Laboratory or diagnostic tests may be ordered as indicated. The visit is documented as a preventive medicine reevaluation and management service for an adolescent, corresponding to CPT code 99394.
Coding Specifications
-
Modifier
25: Used when a significant, separately identifiable evaluation and management service is performed by the same physician on the same day as another procedure or service. -
Modifier
33: Indicates that the service provided is a preventive service.
| Modifier Code | Description |
|---|---|
25 | Significant, Separately Identifiable E/M Service by the Same Physician on the Same Day |
33 | Preventive Services |
- Provider Taxonomies:
| Taxonomy Code | Specialty |
|---|---|
208000000X | Pediatrics |
207Q00000X | Family Medicine |
208D00000X | General Practice |
Related Diagnoses
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Z00.129: Encounter for routine child health examination without abnormal findings- Used when the preventive visit reveals no abnormal findings.
-
Z00.121: Encounter for routine child health examination with abnormal findings- Used when the preventive visit identifies abnormal findings.
-
Z02.5: Encounter for examination for participation in sport- Used when the visit is for a sports physical or clearance for athletic participation.
-
Z71.3: Dietary counseling and surveillance- Used when dietary counseling is provided during the preventive visit.
-
Z71.82: Exercise counseling- Used when exercise counseling is provided as part of the preventive service.
Each diagnosis code reflects a clinical scenario relevant to the preventive medicine evaluation and management service for adolescents.
Related CPT Codes
-
99395: Established patient periodic preventive medicine examination age 18-39 years- Used for preventive medicine visits for established patients aged 18-39. This code is used as patients age out of the adolescent range covered by
99394.
- Used for preventive medicine visits for established patients aged 18-39. This code is used as patients age out of the adolescent range covered by
-
99396: Established patient periodic preventive medicine examination age 40-64 years- Used for preventive medicine visits for established patients aged 40-64. This code follows
99395as patients continue preventive care into adulthood.
- Used for preventive medicine visits for established patients aged 40-64. This code follows
-
99397: Periodic primary re‑evaluation for an established patient 65 and older- Used for preventive medicine visits for established patients aged 65 and older. This code is used for senior patients in preventive care workflows.
These codes are alternatives to 99394 based on patient age and are not typically used together in a single encounter.
National Reimbursement Benchmarks
National mean rates for CPT code 99394 show that UnitedHealth Group leads with $158.35, while the BUCA average (Blue Cross Blue Shield, UnitedHealth Group, Cigna, Aetna) stands at $125.85. Medicare rates are not available in the input for comparison.
Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies across payers. Aetna has the tightest range at $57.25, while UnitedHealth Group exhibits the widest spread at $87.75. Cigna also shows a substantial range of $87.57, indicating greater variability in reimbursement rates. Blue Cross Blue Shield and BUCA have moderate dispersions of $48.49 and $60.78, respectively.
The table and chart below present the full breakdown of national benchmarks for each payer.
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